From the Guidelines
ACE inhibitors or ARBs should not be prescribed to diabetic patients without hypertension or albuminuria, as they have not proven to offer kidney protective effects in this population. The most recent and highest quality study, published in 2024 1, found that ACE inhibitors and ARBs did not improve renal outcomes in people with type 1 and type 2 diabetes who were normotensive with or without high albuminuria.
Key points to consider when deciding whether to prescribe ACE inhibitors or ARBs to diabetic patients include:
- The presence of albuminuria, which is a strong indicator of kidney disease progression and cardiovascular disease risk
- The patient's blood pressure, as ACE inhibitors and ARBs are primarily used to manage hypertension
- The potential risks and benefits of treatment, including the risk of hyperkalemia and decline in GFR
According to the 2024 study 1, ACE inhibitors and ARBs are commonly not dosed at maximum tolerated doses due to concerns about serum creatinine increases, but not maximizing these therapies can be considered suboptimal care. However, in the absence of kidney disease, ACE inhibitors or ARBs have not proven superior to alternative classes of antihypertensive therapy, including thiazide-like diuretics and dihydropyridine calcium channel blockers.
In terms of specific treatment recommendations, the 2021 study 1 suggests that RAS inhibitors should be titrated to the maximal tolerated dose, with close monitoring of serum potassium and serum creatinine levels within 2 to 4 weeks of initiation of or change in dose. However, the 2024 study 1 notes that the combined use of ACE inhibitors and ARBs should be avoided due to higher adverse event rates.
Overall, the decision to prescribe ACE inhibitors or ARBs to diabetic patients without hypertension or albuminuria should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history. The primary goal of treatment should be to manage blood pressure and prevent kidney disease progression, rather than simply prescribing ACE inhibitors or ARBs as a preventative measure.
From the Research
Use of ACE Inhibitors and ARBs in Diabetic Patients
- The use of ACE inhibitors and ARBs in diabetic patients is supported by several studies, including 2, which showed that these drugs have beneficial effects on micro- and macrovascular complications of diabetes.
- The study 3 also demonstrated that ARBs can prevent or delay the development of diabetic nephropathy independently of their blood pressure-lowering effect in patients with type 2 diabetes and microalbuminuria.
- Another study 4 recommended the use of ACE inhibitors as a first-line treatment for mild hypertension in diabetic patients, due to their ability to slow the progression of diabetic nephropathy.
Prescription of ACE Inhibitors and ARBs without Hypertension
- The study 2 suggested that ACE inhibitors and ARBs can be beneficial for diabetic patients even without hypertension, as they can reduce the progression of diabetic nephropathy.
- The study 5 found that physicians' conformity to prescribing ACE inhibitors or ARBs is lower than expected for patients with diabetes and renal disease but without hypertension.
- However, the study 6 noted that combination therapy with an ACE inhibitor and an ARB, or a direct renin inhibitor, may not be more effective than monotherapy with an ACE inhibitor or ARB, and may increase the risk of adverse events.
Patient Adherence to ACE Inhibitors and ARBs
- The study 5 found that patient adherence to ACE inhibitor or ARB therapy, measured by medication possession ratio (MPR), was 0.77, indicating a moderate level of adherence.
- The study also found that older patients were more likely to adhere to their ACE inhibitor or ARB therapy, and that patients with renal involvement and hypertension were more likely to receive an ACE inhibitor or an ARB than those without hypertension.